Tuberculosis Contact Investigation Transfer Form
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1
2Report and Date
Tuberculosis Contact Investigation
-
Initial
____/____/____
Update ____/____/____
RE
FE
RRING
LHD
Transfer Form
(LOCAL H
EA
LTH DEP
ARTMENT)
Final
____/____/____
Referring Case Manager_______________________________
State Case#_________________________________
Local Case#________________________________
CASE INFORMATION
Case Initials________________________
Case Disease Site
Need for Contact Investigation (case characteristics)
High
The following contacts are being referred to the LHD below:
Pulmonary, Pleural, or Laryngeal
(sputum-smear pos and/or cavitary or laryngeal TB)
Med
Other
(sputum-smear neg, culture positive pulmonary or pleural TB)
Low
LHD __________________________________
(sputum-smear neg, culture negative pulmonary or pleural TB)
None
(all others, pulmonary involvement ruled out, contact investigation not needed)
Receiving Case Manager _______________________________
Case Infectious Period
Date of referral ____/____/______
Start Date____/____/____
End Date____/____/____
Pending
CONTACT* INFORMATION - TRANSFER
≥ 8 week TST/QFT
Contact Risks
Symptoms <8 week TST/QFT
CXR
LTBI Treatment
Final Status***
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth
Country of Birth
______________
DOE
DOE
____ ___
/
/
_
Exceeds Exposure Limits
Exceeds Exposure Limits
with inactive TB
with inactive TB
INH
INH
Adverse Rxn to Tx
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
* A contact is a person whom the health department believes had significant exposure,and for whom enough identifying/contacting information is available.
Page 1 of _____
** Relative risk of infection depends on exposure and medical risk factors of the contact. For congregate setting exposures, contact the State for assistance in categorizing the contact's risk of infection.
Revised 4/14/2010
*** Complete for contacts not fully evaluated or contacts starting treatment
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